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Dr Benjamin Undersea, OD Eye Concepts, LLC 331 Killian Rd., Suite B2 Columbia, SC 292038926 Phone: (803)7548370 Fax: (803)7548371 AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION Patient

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1. Begin by carefully reading and reviewing all the instructions provided on the form. It is essential to have a clear understanding of what information is required and how it should be provided.
2. Start by entering your personal details accurately and legibly. This may include your full name, address, contact number, and date of birth. Ensure that all the information entered is up to date and correct.
3. Proceed to provide any relevant medical history information requested on the form. This may include details about any existing medical conditions, allergies, or previous eye-related issues. Be honest and transparent while providing this information as it will assist Dr. Benjamin Ondersma OD in providing appropriate care.
4. If the form requires you to provide information about your vision, make sure to answer the questions accurately. This may include providing details about any symptoms you are experiencing, such as blurred vision, eye pain, or sensitivity to light.
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6. Take your time to review the completed form before submitting it. Double-check for any errors, omissions, or incomplete entries. It is essential to provide a complete and accurate picture of your eye health for Dr. Benjamin Ondersma OD to provide the best possible care.

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1. Individuals with vision problems: If you are experiencing vision difficulties, such as blurred vision, difficulty reading, or eye strain, you may benefit from the expertise of Dr. Benjamin Ondersma OD. He can conduct comprehensive eye examinations, diagnose vision issues, and prescribe appropriate treatments or corrective measures.
2. Patients with eye diseases or conditions: If you have been diagnosed with or suspect you have an eye disease or condition, seeking the assistance of Dr. Benjamin Ondersma OD is crucial. He can provide professional guidance, perform necessary tests, and offer treatment options to manage or improve your condition.
3. Individuals in need of preventive eye care: Regular eye exams are vital for maintaining good eye health and detecting any potential issues early on. Whether you have a family history of eye diseases or simply want to ensure your vision is in optimal condition, scheduling an appointment with Dr. Benjamin Ondersma OD is recommended.
4. Those seeking contact lenses or glasses: If you prefer to wear contact lenses or eyeglasses, Dr. Benjamin Ondersma OD can help determine the most suitable prescription for you. He can assess your visual needs, perform fitting examinations, and provide recommendations for the best eyewear options.

Remember, it is always recommended to consult with Dr. Benjamin Ondersma OD directly to receive personalized advice and guidance based on your specific situation and eye health needs.

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Dr. Benjamin Ondersma, OD is an Optometrist.

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Information such as the date of service, description of service, and cost of service must be reported on the Dr. Benjamin Ondersma, OD form.